New Patient Registration Form

First name

Surname

Email Address

Phone number

Date of birth / /

Place of birth

NHS number

Gender

Date entering UK

Current address

Previous address

Previous GP name and address

Would you like us to contact you via text message in relation to your health and care and to remind you of your appointments? YesNo

Which Health Centre would you like to register with? Read more about our Health Centres here. Bromley by Bow Health CentreSt Andrews Health CentreXX Place Health Centre

Do you have a carer who looks after you? YesNo

Do you look after anyone who is ill, frail, disabled or has mental health or emotional support needs, or substance misuse problems? YesNo

Do you have any medical problems? Please write them below:

Do you have any repeat medications? If yes, please write them below:

Do you have any allergies? Please write them below:

Does anyone in your family have diabetes? If yes, please write who this is below:

Does anyone in your family have heart disease or stroke? Heart diseaseStrokeBothNeither

If yes, who?

Up to date tests to find cervical cancer make it the easiest female cancer to catch early. If you are a woman between 25 - 64 years of age, have you had a smear test in the last 3 to 5 years? YesNoN/A

Have you had 2 doses of MMR? YesNoI don't know

If you are under 25 years of age have you had the meningitis vaccine? YesNoI don't know

We offer all new patients an optional 15 minute new patient health check. In this check, a nurse or health care assistant will take a few measurements including your blood pressure, height and weight. You can also talk about any other areas of your health and wellbeing, including the subjects covered in this form.

Would you like us to book you in a new patient health check? YesNo

We recommend a routine sexual health check for those who are sexually active as many people will not suffer from any symptoms of sexually transmitted diseases. This can be done in the form of a blood test or urine test if you are a man, or a cotton bud swab you take yourself if you are a woman.

Would you like us to confidentially book one for you? YesNo

Do you smoke? YesNo

If yes, how many a day?

Are you interested in quitting smoking YesNoN/A

You might find that other parts of your life are affecting your physical health. We are here to provide support and guidance in these areas. Please tick every box that sounds interesting, and we’ll put you in touch with one of our team.

Money

Bromley by Bow Centre can support you to manage your money on a low budget, get advice on employment law, access benefits and welfare support, reduce your utility costs and deal with debt.

You can also visit the Financially Inclusive Tower Hamlets website which has lots of information www.fith.org.uk

I'm interested

Housing

The advice team at Bromley by Bow Centre can help you with housing advice. You can also get in touch with your housing provider.

I'm interested

Work

Bromley by Bow Centre employment team can support you to find volunteering or work opportunities in the local area.

I'm interested

Alcohol

Bromley by Bow Centre can support you to manage your money on a low budget, get advice on employment law, access benefits and welfare support, reduce your utility costs and deal with debt.

You can also visit the Financially Inclusive Tower Hamlets website which has lots of information www.fith.org.uk

I'm interested

Computer Skills

If you need support to learn how to use a computer, get online and access social media and other services you can attend digital inclusion classes at Bromley by Bow Centre.

I'm interested

By ticking these boxes you give consent that relevant information from this form will be shared with the service.

Is there any additional information about you that you think we should know about? (Additional Needs, BSL, etc.)

Yes! I would like to receive updates via email about news and events from the Bromley by Bow Centre (Community Hub and Health Centres). View our Newsletter Privacy Policy. No. I don't want to receive updates via email.

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Money

Housing

Work

Alcohol

Computer Skills